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Y3 repro > treatment of breast disease > Flashcards

treatment of breast disease Flashcards

1
Q

incidence of breast cancer

A 
1/8 women 
account for 1/4 of malignancies in women 
55, 000 new cases p/a UK
>490 new cases p/a in Grampian 
>9000 diagnosed each year are <50y/o
>11 400 deaths p/a 
~300 new cases p/a in men
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2
Q

risk factors for breast cancer

A 
age - increased incidence
previous breast cancer
genetic: BRCA1, BRCA2 (5%)
early menarche and late menopause
late/no pregnancy
HRT
alcohol (>14 units/wk)
weight
post RT treatment for Hodgkin's disease
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3
Q

why is weight a risk factor for breast cancer

A

increased fat

increased storage of oestrogen

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4
Q

presentation of breast cancer - where would it be picked up

A

asymptomatic - breast screening (50-70y/o)

symptomatic - outpatient clinic

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5
Q

symptomatic presentation of breast cancer

A 
lump 
mastalgia - persistent unilateral pain 
nipple discharge - blood stained
nipple changes - Paget's disease, retraction 
change in size/shape of the breast
lymphoedema - swelling of arm
dimpling of breast skin
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6
Q

new patient clinic - investigations

A

TRIPLE ASSESSMENT

  1. clinical - hx and examination
  2. radiological - bilateral mammograms/US
  3. cyto-pathological - FNA (cells only, cytology), core biopsy (tissue, histopathology)
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7
Q

triple assessment: clinical assessment

A 
HX: 
PC
previous breast problems
FHx
hormonal status
drug Hx

examination:
BOTH breasts - start with normal breast
axillae
SCF - supraclavicular fossae

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8
Q

common signs and symptoms of breast cancer

A

most common - lump/thickening in breast, often painless
discharge or bleeding
change in size/contours of breast
inversion - is this new or has it always been inverted
change in colour/appearance of areola
redness or pitting of skin over breast (peau d’orange) - sign of inflammatory breast cancer

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9
Q

triple assessment: breast imaging

A

mammography, US, MRI
mammography is the most sensitive in older women
MRI - only for lobular cancer, dense breasts or other benign disease present
sensitivity is reduced in young women due to presence of increased glandular tissue (<35y/o)

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10
Q

triple assessment: cytology and histology

A

FNA - cytology

core biopsy - histopathology, invasive VS in-situ ER/PR/HER2 receptor status

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11
Q

how sensitive are the investigations

A

clinical examination 88%
mammography 93%
US 88%
FNA cytology 94% - diagnostic

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12
Q

importance of HER2 receptor status

A

prognostic factor

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13
Q

pathological types of breast cancer

A

invasive:
80% ductal carcinoma
10% lobular carcinoma
10% others - mucinous, tubular, papillary, medullary, sarcoma, lymphoma

non-invasive:
DCIS - ductal carcinoma in situ, 17% screening detected
LCIS - lobular carcinoma in situ

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14
Q

management of cancer

A
  1. diagnosis
  2. staging
  3. definitive treatment
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15
Q

treatment of breast cancer - MDT approach

A 
breast surgeon 
radiologist
cytologist
pathologist
clinical oncologist - systemic and radiotherapy
medical oncologist - systemic therapy
nurse counsellor
psychologist
reconstructive surgeon
patient and partner
palliative care
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16
Q

staging of breast cancer - how do we do it

A

FBC, U+Es, LFTs, Ca2+/PO2-
CXR
others as clinically indicated
no reliable tumour markers

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17
Q

breast cancer TNM staging - T

A 
TX - 1y tumour cannot be assessed
T0 - 1y tumour not palpable 
T1 - clinically palpable tumour <2cm 
T2 - 2-5cm
T3 - tumour >5cm
T4a - invading skin
T4b - invading chest wall
T4c - skin and chest wall invasion 
T4d - inflammatory breast cancer (worst type)
18
Q

breast cancer TNM staging - N

A

N0 - no regional LNs palpable
N1 - regional LNs palpable, mobile
N2 - regional LNs palpable, fixed

19
Q

breast cancer TNM staging - M

A

MX - distant mets cannot be assessed
M0 - no distant mets
M1 - distant mets

20
Q

management/treatment options

A

neoadjuvant (before surgery) VS adjuvant (after surgery)

surgery
+/- RT
+/- chemotherapy
+/- hormonal therapy

21
Q

what are the 2 main types of surgical procedure

A

breast conservation surgery
mastectomy

randomized controlled trials - breast conservation + RT = mastectomy for overall survival in tumours <4cm

22
Q

patients suitable for breast conservation surgery

A

previously - tumour size <4cm, single tumours
BREAST/TUMOUR SIZE RATIO
suitable for RT
patient’s wish! - most important

23
Q

types of therapeutic mammoplasties

A

omega shape - horizontal line across the breast, runs above the nipple
wise pattern - round the nipple then straight down

24
Q

types of mastectomies

A

simple

skin sparing with immediate implant reconstruction

25
Q

surgery to the axilla

A

prognostic info/staging

regional control of disease/eradication in the axilla

26
Q

sentinal LN biopsy

A

first node to recieve lymphatic drainage
first node tumour spreads to
if -ve, rest of nodes in lymphatic basin are -ve
only performed when pre-op axillary US normal/benign

27
Q

treatment of the axilla

A

if SLN is -ve = no further treatment required

if SLN contains tumour = remove them all surgically (clearance = ANC) OR give RT to all the axillary nodes

28
Q

complications of axillary treatment

A

lymphoedema - 10-17%
sensory disturbance - intercostobrachial n.
decrease ROM of shoulder joint
nerve damage (long thoracic, thoracodorsal, brachial plexus)
vascular damage
radiation induced sarcoma

29
Q

factors associated with increased risk of disease recurrence

A

nottingham prognostic index:

  1. lymph node involvement
  2. tumour grade
  3. tumour size

steroid receptor status (ER/PR -ve)
HER2 +ve
LVI - lymphovascular invasion

30
Q

prevention/adjuvant treatment

A

local RT

systemic: hormonal, chemotherapy, targeted therapies

31
Q

radiotherapy - who gets it and how long for

A

all patients after wide local excision as adjuvant treatment
over 3wks
boosts reduce local recurrence (for younger patients)

after mastectomy if there is local involvement/significant LN involvement

32
Q

complications of RT - immediate - longterm

A

skin reaction - skin telangiectasis
radiation pneumonitis
cutaneous radionecrosis/osteonecrosis
angiosarcoma

33
Q

hormonal therapy - who gets it, how does it work, what are the types

A

only for oestrogen +ve cancers
blocks stimulation of cell growth by oestrogen
tamoxigen, aromatase inhibitors

34
Q

tamoxifen - dose, how does it work, effectiveness, who can have it, side effects

A

20mg once daily for 5-10yrs
blocks directly on ER receptor
effective in all age groups (can be given to premenopausal women), more effective given after chemotherapy

thromboembolic events - CI if prev PE/DVT
low risk of endometrial cancer

35
Q

aromatase inhibitors - dose, how does it work, effectiveness, who can have it, side effects

A 
(arimidex 1mg and letrozole 2.5mg)
once daily for 5yrs
inhibiting ER synthesis
should only be used in postmenopausal women
improve disease free survival

osteoporosis

36
Q

chemotherapy - where is the greatest benefit

A

<50y/o

pts w/ increasing adverse prognostic factor - grade 3, LN +ve, ER -ve, HER2 +ve

37
Q

traditional chemotherapy

A

1st gen - CMF combinations, not used anymore
2nd gen - anthracycline combinations (doxorubicin or epirubicin)
3rd gen - taxane based combinations e.g. Docetaxel, more potent

38
Q

oncotype Dx

A

21 gene assay to determine whether chemotherapy is likely to be of benefit
generates recurrence score:
<25 - don’t benefit from chemotherapy
>25 - would benefit

  • info is only from ER+/HER2 -, LN- pts
39
Q

HER2 positivity and anti-HER2 therapy - different types

A

trastuzumab (Herceptin)

pertuzumab - only in neoadjuvant chemotherapy setting

40
Q

HER2 positivity and anti-HER2 therapy - what is it, who gets it, benefits

A

monoclonal antibody against HER2 receptor
pts w/ over-expression of HER2 and chemotherapy
50% decrease risk of recurrence, 33% increase in survival at 3yrs

41
Q

follow up for breast cancer

A

many different protocols - poor evidence base
clinical examination for 1-5yrs
mammogram of breasts at yrly intervals for 3-10yrs
patient is the best person to keep an eye on it
open access to service

42
Q

metastatic spread of breast cancer

A

local - chestwall, skin, nipple

distant - contralateral breast, bone, lung, liver, brain, bone marrow

Y3 repro (47 decks)

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